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Gordon AM, Ng MK, Magruder ML, Schwartz JM, Jason Wong CH, Mont MA. The Association of Dental Caries or Dental Implant Placement Within One Year of Primary Total Hip Arthroplasty on Medical and Implant Complications. J Arthroplasty 2024:S0883-5403(24)00370-X. [PMID: 38649065 DOI: 10.1016/j.arth.2024.04.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 04/13/2024] [Accepted: 04/16/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND Total hip arthroplasty (THA) adverse events among patients who have dental diagnoses remain unclear. We sought to determine if dental caries or dental implant placements increased (1) 90-day medical complications, (2) 90-day readmissions, and (3) 2-year implant-related complications, including periprosthetic joint infections (PJIs) after THA. METHODS A nationwide database for primary THAs from 2010 to 2021 was queried to compare 3 patient cohorts. Patients who had a history of dental implants or caries within 12 months prior to THA (n = 1,179) or 12 months after THA (n = 1,218) were case-matched to patients who did not have dental history (n = 6,090) by age and comorbidities. Outcomes included 90-day complications, 90-day readmissions, and 2-year implant-related complications. Logistic regression models computed the odds ratios (ORs) of complications and readmissions. P values less than .006 were significant. RESULTS Patients who had dental caries or implant placement 12 months before or after THA experienced 1.6-fold greater odds of 90-day medical complications compared to case-matched patients. Readmissions within 90 days increased for patients who had a dental history before (11.7% versus 8.3%; OR: 1.49, P < .0001) and after (14.2% versus 8.3%; OR: 1.84, P < .0001) THA compared to case-matched patients. A dental caries diagnosis or dental implant placement within 12 months following THA increased 2-year implant complications compared to case-matched patients (15.2% versus 9.3%; OR: 1.69, P < .0001), including PJIs (5.3% versus 2.8%; OR: 1.98, P < .0001), dislocations (4.4% versus 2.7%; OR: 1.63, P = .002), and THA revisions (3.9% versus 2.5%; OR: 1.61, P = .005). CONCLUSIONS Dental diagnoses within 12 months of THA are associated with increased medical complications. Dental diagnoses occurring 12 months after THA are associated with greater implant-related complications, including PJIs. Delaying invasive dental procedures for 12 months after THA may be advisable.
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Affiliation(s)
- Adam M Gordon
- Maimonides Medical Center, Department of Orthopaedic Surgery, Brooklyn, New York; Questrom School of Business, Boston University, Boston, Massachusetts
| | - Mitchell K Ng
- Maimonides Medical Center, Department of Orthopaedic Surgery, Brooklyn, New York
| | - Matthew L Magruder
- Maimonides Medical Center, Department of Orthopaedic Surgery, Brooklyn, New York
| | - Jake M Schwartz
- Maimonides Medical Center, Department of Orthopaedic Surgery, Brooklyn, New York
| | - Che Hang Jason Wong
- Maimonides Medical Center, Department of Orthopaedic Surgery, Brooklyn, New York
| | - Michael A Mont
- Rubin Institute of Orthopaedic Surgery, Department of Orthopaedic Surgery, Baltimore, Maryland
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Briguglio M, Wainwright TW, Latella M, Ninfa A, Cordani C, Colombo C, Banfi G, Francetti L, Corbella S. A Proposal for a Multidisciplinary Integrated Oral Health Network for Patients Undergoing Major Orthopaedic Surgery (IOHN-OS). Geriatrics (Basel) 2024; 9:39. [PMID: 38525756 PMCID: PMC10961760 DOI: 10.3390/geriatrics9020039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 03/13/2024] [Accepted: 03/15/2024] [Indexed: 03/26/2024] Open
Abstract
The passing of the years of life physiologically leads to the accumulation of changes in tissues in the oral cavity, influencing dentition, chewing and swallowing mechanisms, and the oral microbiota. Some diseases and medications can aggravate oral symptoms and negatively influence eating behaviours, increasing the likelihood of becoming malnourished. This could make older individuals more vulnerable to complications when undergoing major orthopaedic surgery. Hidden infection foci in the oral cavity are a recognised cause of post-operative periprosthetic joint infections. Dysfunctional oral problems might also compromise feeding after surgery when good nutrition represents a fundamental aspect of a proper recovery. To manage these shortcomings, in this article, the authors hypothesise a multidisciplinary path of care named the Integrated Oral Health Network applied to major Orthopaedic Surgery (IOHN-OS). This peri-operative initiative would include pre-operative oral health screening and risk management by a dental team, patient education programmes before and after surgery, and bedside gerodontology actions like oral care and meal and eating support for fragile individuals. The IOHN-OS has the potential to reshape the concept of suitability for major orthopaedic surgery and generate momentum for designing community-based surveillance programmes that can keep the mouths of older subjects healthy for a long time.
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Affiliation(s)
- Matteo Briguglio
- Laboratory of Nutritional Sciences, IRCCS Orthopedic Institute Galeazzi, 20161 Milan, Italy
| | - Thomas W. Wainwright
- Orthopaedic Research Institute, Bournemouth University, Bournemouth BH8 8FT, UK
- Physiotherapy Department, University Hospitals Dorset NHS Foundation Trust, Bournemouth BH7 7DW, UK
| | - Marialetizia Latella
- Laboratory of Nutritional Sciences, IRCCS Orthopedic Institute Galeazzi, 20161 Milan, Italy
| | - Aurora Ninfa
- Operational Unit of Phoniatry, ASST Fatebenefratelli-Sacco, 20154 Milan, Italy
| | - Claudio Cordani
- Department of Biomedical, Surgical, and Dental Sciences, Università degli Studi di Milano, 20122 Milan, Italy
- Scientific Direction, IRCCS Orthopedic Institute Galeazzi, 20161 Milan, Italy
| | - Cecilia Colombo
- Orthopaedic Biotechnology Laboratory, IRCCS Orthopedic Institute Galeazzi, 20161 Milan, Italy
| | - Giuseppe Banfi
- Scientific Direction, IRCCS Orthopedic Institute Galeazzi, 20161 Milan, Italy
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, 20132 Milan, Italy
| | - Luca Francetti
- Department of Biomedical, Surgical, and Dental Sciences, Università degli Studi di Milano, 20122 Milan, Italy
- Operational Unit of Odontostomatology, IRCCS Orthopedic Institute Galeazzi, 20161 Milan, Italy
| | - Stefano Corbella
- Department of Biomedical, Surgical, and Dental Sciences, Università degli Studi di Milano, 20122 Milan, Italy
- Operational Unit of Odontostomatology, IRCCS Orthopedic Institute Galeazzi, 20161 Milan, Italy
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Schmalz G, Wirtz J, Haak R, Fenske F, Roth A, Ziebolz D. Dental Therapy of Patients Prior to Endoprostheses: A Retrospective, Telephone-Based Cohort Study. Dent J (Basel) 2023; 11:198. [PMID: 37623294 PMCID: PMC10453566 DOI: 10.3390/dj11080198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 08/14/2023] [Accepted: 08/17/2023] [Indexed: 08/26/2023] Open
Abstract
The aim of this study was to assess, whether patients prior to endoprosthesis (EP) visit their dentist for need-oriented therapy and whether this would be associated with the occurrence of complications. Based on a cohort of patients, which was orally investigated prior to EP surgery between 04/2020 and 12/2021, a telephone interview was performed at least six months after EP implantation. Patients were classified into either low-risk (LR), moderate-risk (MR), or high-risk (HR) groups. Participants were interviewed based on a structured questionnaire regarding dental visits, dental therapy, and potential complications during the observational period. Out of the 311 patients from the baseline cohort, 96 patients after EP implantation could be included (participation rate of 31%). Nineteen patients were in LR (20%), 41 in MR (43%), and 36 in the HR group (37%). Overall, 79% (n = 76) of the patients followed the recommendation to visit their dentist; 94% of patients within the HR group visited the dentist (p = 0.02). Dental treatment procedures included tooth cleaning (57%), periodontal treatment (31%), restorative therapy/filling (28%), and tooth extraction (28%). In 64% of the HR patients (n = 23), the potential oral foci with a risk of EP infection were eliminated by their general dentist. Fourteen different complications occurred within the observation period, without any group effect (p > 0.05). In conclusion, most patients prior to EP visit their general dentist following referral, especially if they have a potential oral focus. The effect of dental clearance on infectious complications of EP remains unclear, whereby further clinical studies are needed.
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Affiliation(s)
- Gerhard Schmalz
- Department of Cariology, Endodontology and Periodontology, University of Leipzig, 04103 Leipzig, Germany; (J.W.); (R.H.); (D.Z.)
| | - Julian Wirtz
- Department of Cariology, Endodontology and Periodontology, University of Leipzig, 04103 Leipzig, Germany; (J.W.); (R.H.); (D.Z.)
| | - Rainer Haak
- Department of Cariology, Endodontology and Periodontology, University of Leipzig, 04103 Leipzig, Germany; (J.W.); (R.H.); (D.Z.)
| | - Fabian Fenske
- Department of Maxillofacial Surgery, University of Leipzig, 04103 Leipzig, Germany;
| | - Andreas Roth
- Department of Orthopaedics, Trauma and Plastic Surgery, University Hospital Leipzig, 04103 Leipzig, Germany;
| | - Dirk Ziebolz
- Department of Cariology, Endodontology and Periodontology, University of Leipzig, 04103 Leipzig, Germany; (J.W.); (R.H.); (D.Z.)
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Fenske F, Krause L, Meyer S, Kujat B, Repmann J, Neuhaus M, Zimmerer R, Roth A, Lethaus B, Ziebolz D, Schmalz G. Oral Health Screening for Risk Reduction for Early Periprosthetic Joint Infections of Hip and Knee Endoprostheses-Results of a Prospective Cohort Study. J Clin Med 2023; 12:4451. [PMID: 37445486 DOI: 10.3390/jcm12134451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 05/29/2023] [Accepted: 06/28/2023] [Indexed: 07/15/2023] Open
Abstract
This prospective observational study had two aims: (I) to assess whether a preoperative dental screening before endoprosthesis (EP) implantation with need-based dental intervention would decrease the prevalence of periprosthetic joint infection (PJI) and (II) to evaluate whether instructed orthopedic surgeons would achieve similar results in oral screening as dentists. The preoperative oral health statuses of the patients, prior to EP insertion, were either evaluated by the patients' general dentists (Ia) or, if the patient had not visited a general dentist, by an instructed orthopedic surgeon (Ib). Both the dentist and orthopedic surgeon used standardized risk estimation (low risk, moderate risk, and high risk) for an oral-health-related infectious complication after EP insertion, including a recommendation for further management of the patient. If required, a need-based dental rehabilitation was performed. In addition, retrospective data evaluation of a comparison group (II) was performed, which had not been screened orally preoperatively. A total of 777 patients (screening group (I): n = 402, of which 229 were screened by a dentist (Ia), 173 were screened by an orthopedic surgeon (Ib); comparison group (II): n = 375) were included. No general association between early infection rate and preoperative oral screening in general was found (1% PJI in screening group (I), 1.6% PJI in comparison group (II); p = 0.455). However, screening performance (dentist vs. orthopedic surgeon) had a significant impact on the prevalence of developed PJIs (p = 0.021). Thereby, 100% of observed infections in the screening group (I) occurred in the group with previous oral screening by an orthopedic surgeon (Ib). Furthermore, the C-reactive protein (CRP) value at discharge was significantly lower when general preoperative oral screening had been performed (group I vs. group II, p = 0.03). Only preoperative oral screening by a dentist had the potential to reduce oral-focus-associated EP infections; therefore, increased attention should be paid to the further promotion of interdisciplinary work between dentists and orthopedic surgeons. Dental screenings, using objectifiable criteria, as applied in this study, seem reasonable but require further validation in larger cohorts.
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Affiliation(s)
- Fabian Fenske
- Department of Oral and Maxillofacial Surgery, University of Leipzig, 04103 Leipzig, Germany
| | - Leah Krause
- Department of Cariology, Endodontology and Periodontology, University of Leipzig, 04103 Leipzig, Germany
| | - Stephan Meyer
- Department of Oral and Maxillofacial Surgery, University of Leipzig, 04103 Leipzig, Germany
| | - Benjamin Kujat
- Specialised Clinic for Orthopedics, Mediclin Waldkrankenhaus Bad Düben, 04848 Bad Düben, Germany
| | - Jacqueline Repmann
- Specialised Clinic for Orthopedics, Mediclin Waldkrankenhaus Bad Düben, 04848 Bad Düben, Germany
| | - Michael Neuhaus
- Department of Oral and Maxillofacial Surgery, University of Leipzig, 04103 Leipzig, Germany
| | - Rüdiger Zimmerer
- Department of Oral and Maxillofacial Surgery, University of Leipzig, 04103 Leipzig, Germany
| | - Andreas Roth
- Department of Orthopedics, Trauma and Plastic Surgery, University Hospital Leipzig, 04103 Leipzig, Germany
| | - Bernd Lethaus
- Department of Oral and Maxillofacial Surgery, University of Leipzig, 04103 Leipzig, Germany
| | - Dirk Ziebolz
- Department of Cariology, Endodontology and Periodontology, University of Leipzig, 04103 Leipzig, Germany
| | - Gerhard Schmalz
- Department of Cariology, Endodontology and Periodontology, University of Leipzig, 04103 Leipzig, Germany
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Kwan SA, Lau V, Fliegel BE, Baker C, Courtney PM, Deirmengian GK. Routine Preoperative Dental Clearance for Total Joint Arthroplasty: Is There a Benefit? Cureus 2023; 15:e41352. [PMID: 37546155 PMCID: PMC10399090 DOI: 10.7759/cureus.41352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2023] [Indexed: 08/08/2023] Open
Abstract
Background Periprosthetic joint infections (PJIs) place significant psychological and financial burdens on patients and healthcare systems. One measure to reduce the risk of PJIs is preoperative dental screening, for which there is no current consensus recommendation. This study aims to determine whether there is a difference in the rate of PJI and microorganism profile in patients who did and did not obtain preoperative dental clearance. Methodology A retrospective review was conducted among patients undergoing primary total hip arthroplasty and total knee arthroplasty from 2017 to 2021. A cohort of 8,654 patients who underwent routine dental clearance was matched with a cohort of patients who did not. Surgeons who changed their dental clearance protocol were also identified, and the rates of PJIs were compared before and after. Results No statistically significant difference was seen in the rate of PJIs between patients who did and did not undergo routine preoperative dental clearance. No statistically significant difference was seen in the rate of PJIs before and after for surgeons who changed their dental clearance protocol. The microorganism profile between the groups was also found to be without differences. Conclusions Eliminating dental clearance from routine preoperative clearance does not appear to increase the rates of acute PJIs following elective total joint arthroplasty (TJA) or to change the organism profile of the infections that did occur. It may be reasonable to not require routine preoperative dental clearance or to practice selective dental clearance in patients undergoing elective TJA, especially given the increased financial cost and delay in care experienced by patients.
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Affiliation(s)
- Stephanie A Kwan
- Orthopaedic Surgery, Jefferson Health New Jersey, Stratford, USA
| | - Vincent Lau
- Orthopaedic Surgery, Jefferson Health New Jersey, Stratford, USA
| | - Brian E Fliegel
- Orthopaedic Surgery, Jefferson Health New Jersey, Stratford, USA
| | - Colin Baker
- Orthopaedic Surgery, Rothman Orthopaedic Institute, Philadelphia, USA
| | - Paul M Courtney
- Orthopaedic Surgery, Rothman Orthopaedic Institute, Philadelphia, USA
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6
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Gordon AM, Ng MK, Erez O, Wong CH, Mont MA. The Importance of Oral History: Does Dental Implant Placement or Caries One Year Before or After Primary Total Knee Arthroplasty Increase Medical Complications and Periprosthetic Joint Infections? J Arthroplasty 2023; 38:476-483. [PMID: 36252742 DOI: 10.1016/j.arth.2022.10.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 10/04/2022] [Accepted: 10/10/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Consensus regarding prior dental problems on the outcomes of total knee arthroplasty (TKA) patients is lacking. Therefore, our objectives were to determine the association of dental caries or dental implant placement in TKA patients on the following: (1) medical complications; (2) health care utilization (lengths of stay and readmissions); (3) implant-related complications; and (4) expenditures. METHODS A retrospective query was performed using an administrative claims database for 3 patient cohorts undergoing primary TKA from 2010 to 2020. Patients who had a history of dental caries or implant placement 1 year prior to TKA (n = 1,466) and 1 year after TKA (n = 1,127) were case-matched to patients who did not have a dental history by age and comorbidities. Outcomes included 90-day complications, health care utilization parameters, 2-year implant complications, and expenditures. Logistic regression models computed odds ratios (OR) of complications and readmissions. P values less than 0.005 were significant. RESULTS Patients who had a dental implant placement prior to TKA had higher frequency of complications (20.05 versus 14.01%; OR: 1.53, P < .0001), including myocardial infarctions (2.52 versus 1.23%; OR: 2.08, P = .0002) and pneumonia (2.52 versus 1.24%; OR: 2.06, P = .0002). Lengths of stay (3.28 versus 2.98 days; P = .255), readmission rates (4.71 versus 4.28%; P = .470), and implant-related complications including periprosthetic joint infections (3.14 versus 2.63%; OR: 1.20, P = .279) were similar between patients lacking dental history. Expenditures were higher in patients who had a postoperative and preoperative dental history ($19,252 versus $19,363 versus 17,980; P < .001). CONCLUSION Dental caries or implant placement may reflect overall worse medical condition resulting in more complications and higher costs after TKA. Dental history screening preoperatively may assist arthroplasty surgeons in minimizing complications.
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Affiliation(s)
- Adam M Gordon
- Department of Orthopaedic Surgery, Maimonides Medical Center, Brooklyn, New York
| | - Mitchell K Ng
- Department of Orthopaedic Surgery, Maimonides Medical Center, Brooklyn, New York
| | - Orry Erez
- Department of Orthopaedic Surgery, Maimonides Medical Center, Brooklyn, New York
| | - Che H Wong
- Department of Orthopaedic Surgery, Maimonides Medical Center, Brooklyn, New York
| | - Michael A Mont
- Department of Orthopaedic Surgery, Rubin Institute of Orthopaedic Surgery, Baltimore, Maryland
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Movement Is Life-Optimizing Patient Access to Total Joint Arthroplasty: Dental Health Disparities. J Am Acad Orthop Surg 2022; 30:1036-1038. [PMID: 34478412 DOI: 10.5435/jaaos-d-21-00426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 05/30/2021] [Indexed: 02/01/2023] Open
Abstract
Poor oral health is common in the United States; however, it is much more common in African Americans, Hispanics, and other racial/ethnic minorities. Almost one in five low-income adults states that their mouth and teeth are in poor condition. Twenty-nine percent of Americans have no dental insurance. Patients who have active infections are at greater risk for prosthetic joint infection. Optimization in these vulnerable groups should focus on treating active infections, with a prioritization of free clinics, academic clinics, and websites, such as "The Neighborhood Navigator," and easily accessible surgical consults.
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Scott RD. Avoiding Sepsis After Total Knee Arthroplasty: Be Gentle, Vigilant, and Proactive. Arthroplast Today 2022; 15:9-12. [PMID: 35345442 PMCID: PMC8956843 DOI: 10.1016/j.artd.2022.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 02/16/2022] [Indexed: 11/30/2022] Open
Affiliation(s)
- Richard D. Scott
- Corresponding author. 10 Nickerson Rd, Dedham, MA 02026, USA. Tel.: +1 617 966 6056.
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Tye EY, Taylor AJ, Kay RD, Bryman JA, Andrawis JP, Runner RP. An Orthopedic Surgeon's Dental Examination: Reducing Unnecessary Delays in Joint Replacement Surgery for Marginalized Patients in a Safety Net Hospital System. Arthroplast Today 2021; 12:76-81. [PMID: 34805467 PMCID: PMC8585792 DOI: 10.1016/j.artd.2021.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 10/01/2021] [Indexed: 12/01/2022] Open
Abstract
Background Selective dental clearance before total joint arthroplasty (TJA) has been proposed; however, effective strategies of carrying out this practice are lacking. This study aims to determine the positive predictive value (PPV) of a novel oral examination performed by an orthopedic surgeon to better direct limited resources for marginalized patients in a safety net hospital system. Methods A retrospective review was conducted on 105 consecutive patients who had an oral examination performed by a single surgeon before elective TJA. Patients who screened negative proceeded to surgery without further formal dental clearance. Patients who screened positive underwent formal examination/intervention by a dentist before surgery. The rate of correct referral that resulted in patients undergoing an oral surgical intervention was determined. Complications during a minimum 90-day postoperative follow-up period were collected and compared. Results Thirty patients (28.6%) screened positive while 75 patients (71.4%) screened negative and proceeded to surgery without referral. The PPV of the screening test was high, with 73.3% of patients receiving a major surgical oral intervention before TJA. Patients sent for formal referral required 89.1 more days to receive their surgery than those that screened negative (54.9 days ± 4.24 vs 144.0 days ± 82.4, P < .001). Conclusion An orthopedic surgeon’s oral examination demonstrates a high PPV to identify high-risk patients in need of an oral surgical intervention before TJA. This provides a unique solution regarding over-referral for preoperative dental clearance and avoids delays for marginalized patients considering elective TJA in a safety net hospital system.
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Affiliation(s)
- Erik Y Tye
- Rancho Los Amigos National Rehabilitation and Medical Center, Downey, CA, USA.,Harbor-University of California, Los Angeles, Medical Center, Torrance, CA, USA
| | - Adam J Taylor
- Rancho Los Amigos National Rehabilitation and Medical Center, Downey, CA, USA.,Harbor-University of California, Los Angeles, Medical Center, Torrance, CA, USA
| | - Robert D Kay
- Rancho Los Amigos National Rehabilitation and Medical Center, Downey, CA, USA.,Harbor-University of California, Los Angeles, Medical Center, Torrance, CA, USA
| | - Jason A Bryman
- Rancho Los Amigos National Rehabilitation and Medical Center, Downey, CA, USA.,Harbor-University of California, Los Angeles, Medical Center, Torrance, CA, USA
| | - John P Andrawis
- Rancho Los Amigos National Rehabilitation and Medical Center, Downey, CA, USA.,Harbor-University of California, Los Angeles, Medical Center, Torrance, CA, USA
| | - Robert P Runner
- Rancho Los Amigos National Rehabilitation and Medical Center, Downey, CA, USA
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